Psychosocial Psychosocial Consequences of Disaster Consequences of Disaster

in Childrenin Children

PDLS version 2PDLS version 2

draftdraft

Gretchen K. Lipke, MDGretchen K. Lipke, MD

ObjectivesObjectives

The student will be able to describe:The student will be able to describe: Expected reactionsExpected reactions Unhealthy reactionsUnhealthy reactions Coping mechanismsCoping mechanisms Family role in child’s responseFamily role in child’s response

It is impossible to separate the It is impossible to separate the effects of disaster on children and effects of disaster on children and their families and the two should be their families and the two should be considered as a unit.considered as a unit.

Children in DisasterChildren in Disaster

Mass casualty events affect childrenMass casualty events affect children• Directly, as victimsDirectly, as victims• Indirectly, as families are affected Indirectly, as families are affected

Children as Direct VictimsChildren as Direct Victims

Children as indirect victimsChildren as indirect victims

Oklahoma CityOklahoma City

3200 high school students in city 3200 high school students in city given screening questionnaire 7 given screening questionnaire 7 weeks after bombingweeks after bombing

1/3 knew someone killed1/3 knew someone killed Retrospective scores of initial arousal Retrospective scores of initial arousal

and fear predictive of PTSD at 7 wksand fear predictive of PTSD at 7 wks Raised concerns about TV impact on Raised concerns about TV impact on

traumatized youthtraumatized youth

Children as VictimsChildren as Victims

Psychological reactionsPsychological reactions• Immediate Immediate • Short-termShort-term• Long-termLong-term

OverlapOverlap Normal variation by ageNormal variation by age

Jupiter shipping disasterJupiter shipping disaster

Boat sank – 217 teenaged survivorsBoat sank – 217 teenaged survivors At 5-8 year follow-up:At 5-8 year follow-up:

• 111 (52%) had PTSD at some point111 (52%) had PTSD at some point• Control group 3.4% incidenceControl group 3.4% incidence• 90% onset within 6 months90% onset within 6 months• 1/3 recovered within 1 year1/3 recovered within 1 year• 1/3 still have PTSD 8 year after incident1/3 still have PTSD 8 year after incident

Immediate ReactionsImmediate Reactions

Shock, grief, lossShock, grief, loss Helping, as coping mechanismHelping, as coping mechanism AngerAnger Guilt at surviving, at preserving Guilt at surviving, at preserving

material possessions or family when material possessions or family when friends and neighbors did notfriends and neighbors did not

Short-term reactionsShort-term reactions

During and immediately after eventDuring and immediately after event Continuum with immediate and into Continuum with immediate and into

long-termlong-term Overlap; no clear delineation of Overlap; no clear delineation of

changes, and it may differ among changes, and it may differ among survivors, even within family unit.survivors, even within family unit.

BUT children model the adult BUT children model the adult behavior within their family unitbehavior within their family unit

Short term reactionsShort term reactions

DisbeliefDisbelief DenialDenial AnxietyAnxiety GriefGrief AltruismAltruism ReliefRelief

Short-term reactionsShort-term reactions

Grief, loss, anger, guiltGrief, loss, anger, guilt Coping strategiesCoping strategies

• Regression – loss of developmental Regression – loss of developmental milestonesmilestones

• Clinging and increased dependencyClinging and increased dependency• Helpfulness – more useful in older Helpfulness – more useful in older

childrenchildren• Acting out – competing for attentionActing out – competing for attention

RegressionRegression

Common after traumaCommon after trauma Short-lived behavior –few weeksShort-lived behavior –few weeks Not intentional – child needs Not intentional – child needs

reassurancereassurance Thumb sucking, whining, fear of the Thumb sucking, whining, fear of the

dark, loss of toilet training and dark, loss of toilet training and speech patternsspeech patterns

Loss of previous dependability, Loss of previous dependability, confusion, attention seekingconfusion, attention seeking

Short term reactionsShort term reactions

1 week after Armenian earthquake 1 week after Armenian earthquake (12/88), survey of Armenian (12/88), survey of Armenian adolescents in Los Angeles showedadolescents in Los Angeles showed• Strong identification with victimsStrong identification with victims• Felt personally affectedFelt personally affected• Group activities to escape grief Group activities to escape grief

reactionsreactions

Armenian earthquake resultsArmenian earthquake results

• Group pressure to accelerate helping Group pressure to accelerate helping effortsefforts

• Group cohesion improvedGroup cohesion improved• Preference to preserve communal Preference to preserve communal

values, even over helping earthquake values, even over helping earthquake victimsvictims

• ““participation envy” – survivor guilt, participation envy” – survivor guilt, envy and resentment over being envy and resentment over being excluded from a unique and rallying excluded from a unique and rallying communal experience communal experience

Long term reactionsLong term reactions

Coping mechanismsCoping mechanisms• RegressionsRegressions• Acting outActing out• Replaying eventReplaying event• ClinginessClinginess• Attention seeking behaviorAttention seeking behavior

Long term reactionsLong term reactions

Other Other • Somatic complaints – headache and Somatic complaints – headache and

stomach aches commonstomach aches common• Repetitive re-enactment – drawings, Repetitive re-enactment – drawings,

role-playing, dolls and puppetsrole-playing, dolls and puppets• Risk-taking behaviors – thrill seeking, Risk-taking behaviors – thrill seeking,

drug usedrug use• Withdrawal – from school, friends, usual Withdrawal – from school, friends, usual

activitiesactivities

The diagnosis of PTSD The diagnosis of PTSD

Three categories lasting over a Three categories lasting over a month:month:• Re-experiencing of the event through Re-experiencing of the event through

play or trauma specific nightmares.play or trauma specific nightmares.• Routine avoidance of the reminders of Routine avoidance of the reminders of

the event or a general lack of the event or a general lack of responsiveness.responsiveness.

• Increased sleep disturbances, irritability Increased sleep disturbances, irritability and poor concentration.and poor concentration.

Post-Traumatic Stress DisorderPost-Traumatic Stress Disorder

Interpersonal violence or life-Interpersonal violence or life-threatening accidents or disastersthreatening accidents or disasters

More likely after direct exposureMore likely after direct exposure Also if trauma witnessed or loved Also if trauma witnessed or loved

ones involved with associated horror ones involved with associated horror and shockand shock

PTSD factorsPTSD factors

Degree of controllability, Degree of controllability, predictability and perceived threatpredictability and perceived threat

Relative success of attempts to Relative success of attempts to minimize injury to oneself or othersminimize injury to oneself or others

Actual lossActual loss Intensified if wounded, exposed to Intensified if wounded, exposed to

heat, cold or painheat, cold or pain

Symptoms of PTSDSymptoms of PTSD

Stressor/triggerStressor/trigger Re-experiencing the eventRe-experiencing the event Avoidance of remindersAvoidance of reminders Unwanted recollectionsUnwanted recollections At least one month’s durationAt least one month’s duration

Age and developmentAge and development

Infants to teens – broad range of Infants to teens – broad range of abilitiesabilities

Similar responses will manifest Similar responses will manifest differently at different agesdifferently at different ages

Differences by genderDifferences by gender Responses vary by gender. Boys Responses vary by gender. Boys

take longer to recover and exhibit take longer to recover and exhibit aggressive, antisocial and violent aggressive, antisocial and violent behaviors.behaviors.

Girls are more distressed, have more Girls are more distressed, have more verbal emotions, ask more questions verbal emotions, ask more questions and have more frequent thoughts and have more frequent thoughts concerning the disaster.concerning the disaster.

Parental InvolvementParental Involvement Chernobyl follow-up study: 11 years after Chernobyl follow-up study: 11 years after

evacuation, comparison of 300 children evacuation, comparison of 300 children aged 10-12 at time of study evacuated (as aged 10-12 at time of study evacuated (as infants or in utero) with 300 homeroom infants or in utero) with 300 homeroom classmates never in radiation affected classmates never in radiation affected area.area.

Evac moms rated child’s well-being as Evac moms rated child’s well-being as signif worse, esp somatic despite normal signif worse, esp somatic despite normal PE and blood work.PE and blood work.

Evac kids rated their mental health similar Evac kids rated their mental health similar to classmates except for Chernobyl-related to classmates except for Chernobyl-related anxietyanxiety

Chernobyl and adolescentsChernobyl and adolescents

50 adolescents 9 years after accident50 adolescents 9 years after accident Uncertainty about radiation exposureUncertainty about radiation exposure Frequent thoughts about accidentFrequent thoughts about accident Worried about radiation exposure as Worried about radiation exposure as

a cause of any health problemsa cause of any health problems

PTSD in adolescentsPTSD in adolescents

217 young adults who survived 217 young adults who survived shipping disaster in adolescence shipping disaster in adolescence followed for 5-8 yearsfollowed for 5-8 years

Duration and severity of PTSD most Duration and severity of PTSD most strongly related not to disaster-strongly related not to disaster-related factors, but pre-disaster related factors, but pre-disaster vulnerability and whether survivors vulnerability and whether survivors received school-based supportreceived school-based support

Hurricane AndrewHurricane Andrew

92 492 4thth -6 -6thth graders graders 15 months prior – self reports of 15 months prior – self reports of

anxiety, behavior assessment by anxiety, behavior assessment by peers and teachers and academic peers and teachers and academic skillsskills

Repeated testing at 3 and 7 months Repeated testing at 3 and 7 months post-disasterpost-disaster

At 7 months, exposure and pre-At 7 months, exposure and pre-disaster anxiety predictive of PTSDdisaster anxiety predictive of PTSD

Attention seekingAttention seeking

Infants – crying and irritabilityInfants – crying and irritability Toddlers – regression from Toddlers – regression from

developmental milestonesdevelopmental milestones Preschool – hitting and bitingPreschool – hitting and biting School – defiance of home and school School – defiance of home and school

rulesrules Adolescents – truancy, risk-taking Adolescents – truancy, risk-taking

behaviorsbehaviors

Disruption of Normal PatternsDisruption of Normal Patterns The cardinal effect of disaster and children in The cardinal effect of disaster and children in

adolescents is a disruption of their lives adolescents is a disruption of their lives which leads to a loss of reliability, cohesion, which leads to a loss of reliability, cohesion, and predictability.and predictability.

Toddlers respond with increased Toddlers respond with increased dependency.dependency.

School-age children show evidence of trauma School-age children show evidence of trauma with talk and play about trauma and hostility with talk and play about trauma and hostility to peers and family.to peers and family.

Adolescents may also withdraw and have Adolescents may also withdraw and have decreased interest and experience fatigue, decreased interest and experience fatigue, hypertension, hostility and loss of objectivity.hypertension, hostility and loss of objectivity.

Disruption RecommendationsDisruption Recommendations

Parents, teachers, and healthcare workers Parents, teachers, and healthcare workers should create and maintain a predictable should create and maintain a predictable schedule for children.schedule for children.

Night lights, stuffed animals, and Night lights, stuffed animals, and reassurance are helpful.reassurance are helpful.

Compassion is helpful but punishment is Compassion is helpful but punishment is not.not.

Consultation with psychiatrist or Consultation with psychiatrist or psychiatric social worker may be a benefit.psychiatric social worker may be a benefit.

Stress response in childrenStress response in children

““Fight or flight”Fight or flight” Adrenaline/epinephrine mediatedAdrenaline/epinephrine mediated Arousal stateArousal state Increased startle, response, agitationIncreased startle, response, agitation Increased heart rate, respiratory Increased heart rate, respiratory

rate, blood pressure.rate, blood pressure.

Alternate stress responseAlternate stress response

““Freeze and hide”Freeze and hide” Vagal nerve stimulusVagal nerve stimulus Opposite of “fight or flight”Opposite of “fight or flight” Blunted reactions, affect, responsesBlunted reactions, affect, responses Lowered heart rate, respiratory rate, Lowered heart rate, respiratory rate,

blood pressureblood pressure Syncope may resultSyncope may result

Responding to children’s needsResponding to children’s needs

Parental cues most importantParental cues most important Acknowledge danger and frightAcknowledge danger and fright Calm reassurance provides a sense Calm reassurance provides a sense

of safetyof safety Let children know that feeling upset Let children know that feeling upset

is normalis normal Extra time and attention.Extra time and attention.

Responding to children’s needsResponding to children’s needs

Parents should know age appropriate Parents should know age appropriate responsesresponses

Monitor and limit media exposure to Monitor and limit media exposure to disaster coveragedisaster coverage

Early counseling may reduce long Early counseling may reduce long term negative effectsterm negative effects

Rehearsal of plan reduces anxiety Rehearsal of plan reduces anxiety and gives a a sense of controland gives a a sense of control

Responding to children’s needsResponding to children’s needs

Talking through what happenedTalking through what happened Replaying, for younger children, Replaying, for younger children,

similar to talking throughsimilar to talking through Perspective on family impactPerspective on family impact Probability of recurrence or (for Probability of recurrence or (for

distant events) personal impactdistant events) personal impact

Normal RecoveryNormal Recovery

Talking with othersTalking with others Coping mechanismsCoping mechanisms

• Learning healthy mechanismsLearning healthy mechanisms CounselingCounseling

Post disaster interventionsPost disaster interventions

School based group sessions have School based group sessions have worked wellworked well• Kauai 2 years after Hurricane InikiKauai 2 years after Hurricane Iniki• 4200 children grades 2-6 screened for 4200 children grades 2-6 screened for

trauma related psychosocial symptomstrauma related psychosocial symptoms• 248 with highest levels of symptoms 248 with highest levels of symptoms

randomly assigned to individual randomly assigned to individual counseling or groups sessions.counseling or groups sessions.

• Equal improvement maintained at 1 Equal improvement maintained at 1 year follow-upyear follow-up

Hurricane Hugo blew down the Hurricane Hugo blew down the broccolibroccoli

Role-playingRole-playing DrawingsDrawings Expressing the child’s fears through Expressing the child’s fears through

another characteranother character